Concerns raised 3 Failure to use a sepsis screening tool in community healthcare View source Failure to recognise or adopt a UK sepsis clinical toolkit View source Failure to recognise repeated attendances as clinically significant View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Caroline Robey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Caroline Robey was a fit 34-year-old working mother who became unwell and attended community healthcare providers on six occasions over five days. She was initially diagnosed with a viral infection and later diarrhoea and vomiting, before being admitted to hospital with suspected sepsis; despite treatment, she died the following day from Group A streptococcal infection and evolving sepsis. The principal concerns were the absence of sepsis screening by community healthcare providers, failure to adopt available sepsis toolkit resources, and inadequate consideration of her repeated attendances.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use a sepsis screening tool in community healthcare
Wider context from the report “1. No sepsis screening tool was being used by the community health care providers , and so opportunities were lost to consider a diagnosis of sepsis and refer as an emergency for hospital admission and treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise or adopt a UK sepsis clinical toolkit
Wider context from the report “2. A patient safety alert issued 2 September 2014 by NHS England clearly sets out resources available in the provision of a UK sepsis clinical tool kit, but this had not been recognised or adopted by the health care providers involved in this case .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise repeated attendances as clinically significant
Wider context from the report “3. Inadequate note was taken of the number of different attendances Mrs Robey had initiated despite previous good health, and there was no suggestion she was a frequent attender or had ever sought medical assistance inappropriately.
” Open source report
12 Oct 2015 Mrs Withers · Prevention of Future Deaths report Northamptonshire
View report summary
Concerns raised 5 Inadequate policy for calling back a lifeline or third party when the patient cannot receive calls View source Delays in ambulance staff handover to hospital View source Inadequate policy or procedure for saving essential patient medical history in ambulance service electronic data systems View source Inadequate policy on staff abstraction tolerance and levels View source Inadequate policy for obtaining patient medical history during the first 999 call View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Mrs Withers · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Withers, aged 77, suffered a fall at home causing a fracture, significant haemorrhage and cardiac arrest. She died after a 2 hour 50 minute delay before paramedics arrived. The concerns included procedures for obtaining and retaining medical history, calling back a lifeline or third party, staffing levels, and ambulance handover times at hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for calling back a lifeline or third party when the patient cannot receive calls
Wider context from the report “2) The policy in relation to calling back a life line/third party where the patient is unable to receive calls .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance staff handover to hospital
Wider context from the report “5) The policy and protocol in relation to hand over times between East Midlands Service paramedics and Kettering General Hospital Accident and Emergency staff (the concern being the apparent loss of time by ambulance staff during the handover of patient to hospital .)
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy or procedure for saving essential patient medical history in ambulance service electronic data systems
Wider context from the report “3) The policy/procedure in relation to saving essential patient medical history in the ambulance service electronic data systems .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy on staff abstraction tolerance and levels
Wider context from the report “4) The policy in relation to staff abstraction tolerance and levels .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate policy for obtaining patient medical history during the first 999 call
Wider context from the report “1) The policy in relation to obtaining a patient’s medical history during the first 999 call, reporting an incident .
” Open source report
22 Sep 2015 Stuart Knight · Prevention of Future Deaths report Central Lincolnshire
View report summary
Concerns raised 1 Delays in dispatching ambulances to patients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stuart Knight · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stuart Knight was found unconscious in a road in Wainfleet after apparently falling backwards and hitting his head. There were delays in the arrival of ambulance services, including 1 hour and 24 minutes between the first call and the arrival of the double-crewed ambulance; the report identified these delays as significant and unacceptable. Mr Knight was taken to hospital and died later that day, following a head injury with haemorrhage and skull fracture, with alcohol excess also recorded as a medical cause.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in dispatching ambulances to patients
Wider context from the report “(I) Significant and unacceptable delays occurred in dispatching an ambulance to a patient who was unconscious and had clearly suffered a serious head injury.
Such delay is potentially highly prejudicial to those who rely upon the services provided by EMAS.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate a dynamically deployable single Ambulance Technician vehicle in Skegness and Boston for suitable calls, supported by Clinical Assessment Team referrals or discharge.
Verbatim wording from the response “As a local initiative between the Trust and the commissioning group in east Lincolnshire, a single Ambulance Technician vehicle is available to be deployed dynamically to calls where a traditional double crewed ambulance may not be required, for example a non-injury fall requiring assistance. Supported by the CAT team this resource can suitable respond to a call and through CAT refer or discharge at scene, again negating the need for an ambulance to be deployed. The scheme covers both the Skegness and Boston areas and has run from April 2015 with the following attendances. On average this initiative allows around 40 calls per month to be appropriately and safely assisted, referred and discharged without the need for the attendance of an emergency ambulance.” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the available vehicle fleet to deploy more ambulance resources concurrently.
Verbatim wording from the response “In addition we have invested in our fleet provision to increase the number of vehicles we have available allowing the trust to deploy more resources at any one time.” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Expand the Clinical Assessment Team to provide continuous clinician-led telephone assessment and hear-and-treat support.
Verbatim wording from the response “We have invested significantly in the scope of our Clinical Assessment Team (CAT) based in the emergency operations centre. The CAT team are a group of clinicians, qualified Paramedics and Nurses, who work within the EOC on a 24 hour a day 7 day per week rota. They work providing support and telephone assessment to 999 calls received by the trust. The result of the telephone assessment can, in some serious cases, ensure that a call is dealt with as a higher priority due to clinical need or, in other cases, result in the call being dealt with to a conclusion by the CAT clinician. This is termed as “hear and treat”. In dealing with calls in this manner this ensures that frontline resources are not sent if not required therefore making them available to mobilise to patients with more serious clinical need that require immediate treatment or transport.” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce Paramedic Pathfinder and train frontline staff to use it for pre-hospital assessment and appropriate referral.
Verbatim wording from the response “We have supported our frontline staff with the introduction of Paramedic Pathfinder (PP). PP is a pre hospital assessment guide based around the widely used NEWS (National early warning system) designed to assist crews to identify patients that are suitable for onward referral as opposed to transport to the emergency department. Typically when a patient is not conveyed from their home address (See and Treat), the job cycle time (total time the ambulance is dealing with that particular call and is therefore unavailable) is reduced. Starting in April 2014, by October 2015 94% of staff have completed the training.” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop specialist pathfinder tools and referral services for specific conditions through CQUIN-funded project work.
Verbatim wording from the response “For the longer term this translates into a project based on Commissioning for Quality and Innovation (CQUIN) money to develop specialist pathfinder tools for specific conditions ultimately to identify and” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase frontline and emergency operations centre staffing, including flexible relief capacity for predicted demand.
Verbatim wording from the response “East Midlands Ambulance Service has made significant investment in both staff and vehicle resources since 2014 in both “frontline” staff who attend 999 calls but also in staffing within the emergency operations centre.” Source location 2015-0385-Response-by-East-Midlands-Ambulance-Service
Open published response
Concerns raised 4 Delays in patient care allowing further deterioration and loss of treatment options View source Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability View source Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms View source Failure to escalate stroke-patient collection requests to a medical emergency response View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
George Boulton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
George Boulton developed an intracerebral bleed at home on 12 February 2015 and died on 14 February 2015 at Leicester Royal Infirmary. The report identified delays in arranging emergency transfer and failures to communicate or recognise the need to withhold dalteparin, which materially contributed to the continuing bleed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in patient care allowing further deterioration and loss of treatment options
Wider context from the report “4. This culmination of events in this particular case allowed for the unexpected intervention of the District Nurse; while this is very case specific, similar delays in another patient's care may allow further deterioration and the loss of treatment options .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a bed bureau system for identifying calls requiring emergency admission independently of bed availability
Wider context from the report “2. The bed bureau did not appear from the evidence available in court to have a system for identifying calls that should have been re-routed to an emergency admission , and not be dependent on a bed , as early scanning was essential for proper diagnosis.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to arrange immediate emergency ambulance transfer for potential stroke symptoms
Wider context from the report “1. It was recognised by all witnesses to the inquest that response to potential stroke symptoms should be on an emergency basis , in accordance with "FAST" criteria ie a timely response. The GP attempted to arrange admission but accepted delays via bed bureau rather than convert to a 999 call and obtain immediate ambulance transfer .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate stroke-patient collection requests to a medical emergency response
Wider context from the report “3. East Midlands Ambulance Service did not identify that a request to collect a stroke patient should have been escalated to a medical emergency and a 20 minute response time , rather than the actual allocated 2 hour response time .
” Open source report
9 Apr 2014 Sally Perrons · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6 Insufficient training on the use and interpretation of waveform end-tidal carbon dioxide monitors View source Lack of mandatory use of waveform end-tidal carbon dioxide monitors View source Failure to ensure that all relevant employees have read new guidelines, bulletins and SOPs View source Unavailability of waveform end-tidal carbon dioxide monitors to staff View source Insufficient initial and refresher training for paramedic intubation View source Failure to disseminate new guidelines, bulletins and SOPs to frontline staff View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Sally Perrons · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sally Perrons collapsed at work on 22 January 2013 and was found to be in cardiac arrest. During resuscitation, an endotracheal tube was placed in her oesophagus, but this was not recognised until she reached hospital; she died the following day. The principal concerns were inadequate paramedic intubation training and refresher training, failure to use waveform end-tidal carbon dioxide monitoring, and poor dissemination of relevant guidance to frontline staff.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient training on the use and interpretation of waveform end-tidal carbon dioxide monitors
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them .
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory use of waveform end-tidal carbon dioxide monitors
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all relevant employees have read new guidelines, bulletins and SOPs
Wider context from the report “5. (In relation to EMAS only) Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of waveform end-tidal carbon dioxide monitors to staff
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff , and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient initial and refresher training for paramedic intubation
Wider context from the report “I am concerned that most of these issues will relate not only to EMAS, but nationally, and I therefore address points 1 to 4 below to all ambulance services in England and Wales, via AACE. Point 5 below relates to EMAS only.
1. The level of training associated with paramedic intubation – both initial training and subsequent refresher training, particularly given how infrequently most paramedics are called upon to intubate.
2. Whether use of waveform end-tidal carbon dioxide monitors is now mandatory.
3. Availability of these devices to staff, and training on how to use and interpret them.
4. In the absence of radical changes, in particular in relation to initial and refresher training, ambulance services should consider whether paramedics should be permitted to intubate patients at all.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate new guidelines, bulletins and SOPs to frontline staff
Wider context from the report “5. (In relation to EMAS only) Dissemination of new guidelines/bulletins/SOPs etc to frontline staff and ensuring that all relevant employees have read this.
” Open source report
Concerns raised 1 Lack of training provision for paramedics assisting births View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Lucy Hannah Rose Bailey · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Lucy was born at home following a difficult labour in which her head was delivered but her body did not initially follow. She was not breathing at birth, suffered irreparable brain damage from oxygen starvation, and died the following day. The principal concern was whether paramedic training manuals and guidelines should permit gentle traction to the baby’s head and/or gentle internal manipulation during birth.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to East Midlands Ambulance Service NHS Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of training provision for paramedics assisting births
Wider context from the report “That consideration should be given to amend the training manuals and guidelines to provide for the training of paramedics to assist a birth by providing gentle traction to the baby’s head and/or gentle internal manipulation of the baby whilst in the mothers vagina .
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations